PRIMARY CARE:
Regional strategies to improve efficacy and equity while guaranteeing
economic sustainability
Pisa, June 13, 2011
STRATEGIES AND NEW
MEASUREMENTS IN PRIMARY CARE:
THE CREG PROJECT
IN LOMBARDY REGION
Carlo ZOCCHETTI
Direzione Generale Sanità – Regione Lombardia
DG SANITA’ 1
Just for starting …
24,000 SqKm
9.8 million inhab’s (17% Italy)
LOMBARDY
17 Billion Euros health expen’s
(17% Italy)
Rome
LOMBARDY
A significant proportion
of mountaineous terrain
DG SANITA’
Lombardy Region
•GDP (per cap) 33,648 €
(Italy 26,278 €)
•220 Hospitals (30% profits)
•4 beds x 1,000 inhab’s
•8,150 GPs
•2,700 Pharmacies
•730 Outpatient ambul’s
DG SANITA’
Lombardy Region
•2 Mln discharges
•10% discharges for non
residing people (50% in
oncology, cardiosurgery)
•3,8% passive mobility
•160 Mln outpatient services
•60 Mln drug prescriptions
DG SANITA’
15 LOCAL HEALTH AUTHORITIES (ASL)
100 Districts
DG SANITA’
General rules: Lombardy Region HS
• L.R. Health System:
– Universal coverage; funded by general
taxation; separation between
Purchasers (ASL) and Services
Providers (Hospitals, Ambulatories,
GPs, …)
– Purchasers funded by weighted
capitation; Services Providers funded
(mainly) on delivery of services (DRGs,
List of outpatient activities, tariffs)
6
DG SANITA’
CReG: the problem
• L.R. Health System:
– Centered on hospitals, and acute care:
inadequate to manage chronicity
• Requires different ideas, culture,
competence, tools, instruments
• CReG: Accent on Chronicity, not primary
care
– People is getting older:
• Big proportion of citizens with chronic
diseases or conditions
– Some figures about chronicity in
Lombardy Region
7
DG SANITA’
6,000,000
(54,5%)
Population
5,297,280
5,000,000
70% of
expend’s
4,000,000
(27,5%)
3,000,000
2,000,000
2,676,224
(17,0%)
1,656,380
1,000,000
(0,9%)
87,044
0
Non_Cons
Acute
Chronic
Death
100
Percentage of population
90
80
70
60
50
40
30
20
10
0
3
6
9
12
15
18
21
24
27
30
33
36
39
42
45
48
51
54
57
60
63
66
69
72
75
78
81
84
87
90
93
96
99
0
%Non-Consumers
%Non-Chronic
%Chronic
1,200,000,000
Total expenditures (Euro)
Total
1,000,000,000
800,000,000
Chronic
600,000,000
400,000,000
200,000,000
Acute
95+
90-94
85-89
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
05-09
00-04
0
Only
Disease
Transplants
Number
%
Not Only
Euro/PC
Number
%
Euro/PC
618
0,0
5.543
6.857
0,2 21.846
2.245
0,1
7.815
41.701
1,0 12.956
15.227
1,0
7.455
27.425
0,6
9.486
104.720
6,6
3.518
297.704
6,9
5.195
87.371
5,5
895
426.424
9,9
2.921
Cardiovascular
835.231
52,8
1.166
1.754.271 40,9
2.450
Pulmonary Dis
116.701
7,4
1.169
242.828
5,7
2.981
Gastro&Liver
143.076
9,0
1.269
494.394 11,5
4.014
Neurological
93.662
5,9
2.449
225.720
5,3
4.133
Autoimmune Dis
18.314
1,2
1.146
77.658
1,8
2.306
164.445
10,4
904
693.816 16,2
2.710
Kidney Insuff
HIV-AIDS
Cancer
Diabetes
Endocr_Methabol
CReG: the motivations
• The chronic patient uses many services
which do not resolve his problems
– Live longer with chronicity
– Delay negative consequencies
– Needs control, monitoring, and
organizational acitivities: no specialization
• The chronic patient requires treatment
planes, guidelines, for specific diseases
– Agreed
– Finalized to obtain “continuity of care”
– Some problems
12
DG SANITA’
Antidiabetics
Treated
Statins
Antihypertensiv
Mal
Fem
Mal
Fem
Mal
Fem
Sporadic
19,7
22,5
24,3
24,7
19,8
22,5
Adherent
38,6
38,2
26,4
20,8
42,0
34,7
Not
adherent
61,4
61,8
73,6
79,2
58,0
65,3
Persistent
57,6
58,6
51,5
46,5
57,1
50,6
Not
persistent
42,4
41,4
48,5
53,5
42,9
49,4
CReG: the motivations
• The chronic patient needs to be
maintained “on care”
– Not guaranteed by hospitals acute
approach
– Coordination between hospitals and
primary care
• Is primary care prepared to face
chronicity?
– It lacks some necessary attributes:
• Contractual conditions
• Clinical, management and administrative
expertise
14
DG SANITA’
CReG: the approach
• We need a new institutional subject:
– A manager of a group of many cases
• In the context of L.R. health system
general characteristics:
– Freedom of choice of provider
– Purchaser-provider split
– Accreditation
– Parity between public and private
companies
• The approach emerged after some
experiences, mainly with GPs
15
DG SANITA’
CReG: the approach
• CReG: “Chronic Related Group”
– Innovative way of taking care of chronic
cases
– A group of predefined resources (tariff)
assigned to an institutional subject to
guarantee the delivery of an established
treatment plan to chronic patients it has in
charge
– Services excluded:
• Hospital discharges
• GPs fees
16
DG SANITA’
CReG: the approach
• CReG requires three technological
pillars:
– Ability to classify people with regard to
chronicity (type of diseases, staging, …)
– An established treatment plan, guidelines
– A reimbursement scheme (CReG tariff and
some administrative stuffs)
• CReG requires an organizational
platform
17
DG SANITA’
CReG: the pillars
• 1. CReG: how to classify people
– A specific information system
• Hospital discharges, outpatient ambulatory
services, drug consume
• On an individual basis (PIN)
• Paid with a pps scheme (tariffs)
• Services purchased outside the region
• Large coverage (98% of expenditures)
• No GPs activities
• No “pure private” activities
– A classification scheme
• Also with “disease exemptions”
18
DG SANITA’
Hospital DISCHARGES
DRUGS Consumes
OUTPATIENTS Activities
MORTALITY
PSYCHIATRY
CITIZEN
PATHOLOGY Exam’s
SUPPORT and
Others
SUPPLY
CANCER Registries
CReG: the pillars
• 1. CReG: how to classify people
– A specific information system
• Hospital discharges, outpatient ambulatory
services, drug consume
• On an individual basis (PIN)
• Paid with a pps scheme (tariffs)
• Services purchased outside the region
• Large coverage (98% of expenditures)
• No GPs activities
• No “pure private” activities
– A classification scheme
• Also with “disease exemptions”
20
DG SANITA’
1
exemption
if
code 048*
(or code
0043)
3
drugs
2
discharges
if
or
if
code
ICD9-CM
between
140*
and 208*
Or V10*
1
4
out-patient
ATC L01 or
Chemiother.
or
2
if
3
Cancer
4
or
Radiother.
(code 92.24*)
CReG: the pillars
• 1. CReG: how to classify people
– The classification scheme produced a huge
number of classes
– Ranking of the diseases (according to
expenditures), and selection of the first two
– A manageable number of CReGs (some
hundreds)
• 2. CReG: treatment plans
– They identify needs for specific diseases
– Experts collected and discussed treatment
plans and guidelines
23
DG SANITA’
CReG: the pillars
• 3. CReG: a reimbursement scheme
– To reimburse a global treatment plan (like
DRG), not individual activities (like drugs,
visits, examinations, …)
– Two methodological questions:
• How to set a tariff
• How to manage reimbursement from the
administrative point of view
– How to consider complexity (more than two
diseases in the same patient)
• For each CReG: number of diseases
• Linearity in expenditures according to
24
complexity
DG SANITA’
Examples of linearity of expenditures
According to complexity
L4 - Ipertesi, Ipercolesterolemie Familiari E Non
B1 - Parkinson, Cardiopatici
A1 - Neoplastici, Parkinson
Totale
Totale
Lineare (Totale)
Lineare (Totale)
4500
3000
4000
Lineare (Totale)
4000
3500
2500
3500
Totale
3000
3000
2000
2500
2500
1500
2000
1500
2000
1500
1000
1000
1000
500
500
0
500
0
L42
L43
L44
L45
C9 - Cardiopatici, Ipertesi
0
B12
B13
B14
B15
28 - Insufficienti Renali Cronici, Neoplastici
Totale
Lineare (Totale)
Lineare (Totale)
2000
16000
3000
2500
10000
2000
8000
1500
6000
1000
4000
500
500
2000
0
0
C92
C93
C94
C95
A15
Lineare (Totale)
3500
12000
1000
A14
Totale
18000
14000
1500
A13
F6 - Gastropatici, Ipertesi
Totale
2500
A12
0
282
283
284
285
F62
F63
F64
F65
Ipertesi
CREG
Media
Mediana
CReG: the pillars
• 3. CReG: a reimbursement scheme
– 150 different CReGs
– A basic tariff for each CReG
– An incremental tariff for each additional
disease
– Examples
30
DG SANITA’
CReG
Chronic kidney insuff. with dialisis, hypertension
Basic Incremen
Tariff tal Tariff
34.702
Chronic kidney insuff. without dialisis,
1.666
hypertension
Chronic kidney insuff. without dialisis, gastro&liver 1.149
1.356
1.049
375
Hypercholesterol, hypertension
1.014
530
Hypercolesterol, asthma
1.391
534
Insulinic diabetes, transplant (inactiv)
5.252
389
Diabetes, Parkinson
2.504
289
COPD, cardio-vasculopatic
2.262
579
Asthma, diabetes
1.588
235
Cardio-vasculopatic, systemic Lupus
heritematosus
Hypertension, rheumatoid arthritis
1.477
650
1.003
566
CReG: the organizational platform
• 4. CReG: the organizational platform
– A new institutional subject
• A group of GPs
• Association of patients, or professionals
• Any type of provider (hospitals, ambulatories,
…) private or public
• Must be accredited (establish criteria and rules)
• Must sign a contract with ASL
– Patients will receive a defined set of
activities (treatment plan)
32
DG SANITA’
CReG: the organizational platform
• 4. CReG: the organizational platform
– Accreditation:
•
•
•
•
Organizational and managerial attributes
Professional skills (clinical expertise)
Information system
………
– Contract:
• Duties for the institutional subject
– Patients interested, expected needs, treatment plans,
managerial activities, information exchanged
• Duties for the ASL
– Reimbursement scheme, control activities
33
DG SANITA’
… and just for closing …
• Next months:
– A restricted application of CReG approach
– In five areas:
• Bergamo, Como, Lecco, Melegnano, Milano
– For some diseases:
• Diabetes, hypertension, COPD, kidney
insufficiency, …
– Objectives:
• To fine tune the CReG approach
• Particularly: organizational, managerial,
administrative aspects
34
DG SANITA’
DG. SANITA’
Carlo Zocchetti
Thank you
for
attention
and
patience
Marc Chagall: The Violinist